● Oral care is an integral part of holistic patient/client centered care

● Act in the best interest of your patient/client at all times

● Act where you are competent and within your scope of practice –

be accountable

● Meet the standards of practice of your profession

● IPC is proven to improve patient/client care outcomes.3 Oral care of

invasively ventilated patients/clients requires IPC teamwork due to

associated risks (e.g., aspiration and accidental loss of airway)

● Define your role and scope on your oral health care team and

understand the roles/scopes of the other health care providers

● Evidence-based oral care reduces VAP. Advocate for standardization

and adoption of evidence-based best practices based on Safer

Healthcare Now! VAP Bundle

● Communicate and Document

Suggested Next Steps for CRTO/CDHO

● Joint communiqué(s)

● Presentations, posters, abstracts, papers

Conferences (e.g. Respiratory Therapy Society of Ontario [RTSO]

Educational Forum Fall 2011 or Ontario Dental Hygienists’

Association [ODHA])

Interprofessional Forum(s) (e.g. Federation of Health Regulatory

Colleges)

At hospitals and other organizations (e.g. Education Days)

● Interprofessional Education (IPE) – Canadore, Algonquin, La Cité, and

Fanshawe colleges have both approved RT and DH programs

● Share with the other health regulatory colleges (e.g. Nurses, Speech

Language Pathologists, etc.)

Was This A Successful IPC Project? YES

CIHC Goal of IPC

“A partnership between a team of health providers and a client in a

participatory, collaborative and coordinated approach to shared

decision-making around health and social issues.”5

Acknowledgements

Focus Group Participants

From left to right: Betty Lou Doucette, RRT, Children’s Hospital of Eastern

Ontario (CHEO); Lisa Frisch, RDH, Baycrest Geriatric Health Care System,

Toronto; Jennifer Harrison, RRT, Professional Practice Advisor, CRTO;

Cynthia Harris, RRT, Mount Sinai Hospital, Toronto; Nancy Fasken, RDH,

The Ottawa Hospital; Tara Fowler, RRT, University Health Network, Toronto

(front); Sheilagh Walsh, RDH, Toronto (behind); Miranda Zielinski, GRT,

Kingston General Hospital; Bert Reket, RRT, Vital Aire, Owen Sound; Fran

Richardson, RDH, Registrar, CDHO; Lisa Taylor, RDH, Associate Registrar,

CDHO (not present for photo)

Project Lead and Focus Group Facilitator

Jennifer Harrison, RRT, Professional Practice Advisor, CRTO

Literature Review – Evidence-Based Practice

● Focused on adult, invasively ventilated patients/clients in hospitals

● Oral decontamination prior to intubation can reduce VAP4

● Once intubated and ventilated, most recommendations seem to include

at least twice a day oral decontamination with chlorhexidine solution,

this aligns with Safer Healthcare Now! VAP recommendations

General

● No need for Colleges to generate new best practice guidelines at

this time

● Focus on current evidence-based recommendations for adult, invasively

ventilated patients/clients

● “Oral care should be integrated into the care plan of all intubated

patients” (SHN, 2012, p.25)

Summary Clinical Recommendations

● Use routine precautions and additional precautions including Personal

Protective Equipment (PPE) when aerosolized droplets are anticipated

● Follow provincial infection prevention and control guidelines (i.e.,

Ontario’s Ministry of Health and Long-Term Care’s Provincial Infectious

Diseases Advisory Committee’s [PIDAC’s] Knowledge Products)

● When possible, oral decontamination prior to intubation1, 4

● Follow Safer Healthcare Now! Prevent VAP Tool Kit (2012). These

guidelines include recommendations for oral decontamination.

“The components of Safer Healthcare Now! VAP Bundle (not

listed in order of importance):

Elevation of the head of the bed to 45° when possible, otherwise attempt to maintain the head of the bed greater than 30° should be considered

Daily evaluation of readiness for extubation The utilization of endotracheal tubes with subglottic secretion

drainage Oral care and decontamination with Chlorhexidine

(e.g., 15mL of 0.12% every 12 hours) Initiation of safe enteral nutrition within 24-48h of ICU

admission.”

● Reduce risk, have two people perform oral care of invasively

ventilated patients/clients

● For optimal results, do not rinse the oral cavity within 30 minutes of

oral decontamination with chlorhexidine

● Chlorhexidine may cause staining of the teeth but can be

professionally removed – consult an RDH

● Mechanical decontamination with a toothbrush is recommended as well

as flossing whenever possible (use of swabs/sponges are not

recommended best practice)

● Maintain the cleanliness (and sterility) of your environment and oral

care tools/products

● Document your care in the patient’s/client’s medical records

● Monitor and inquire about the quality improvement and safety

outcomes of providing best practices for oral health care

Professional Practice Recommendations

● Oral care can reduce the incidence of Ventilator-Acquired Pneumonia

(VAP).1, 2

● “Interprofessional care can help improve patient/client care while

increasing provider satisfaction within a respectful and collaborative

environment.”3

● Together, the CRTO and the CDHO can advocate for best oral care

practices to ensure high quality, safe and ethical care in the best

interest of mechanically ventilated patients/clients in Ontario.

● To review existing oral care practices to determine if current practices

align with evidence-based best practice recommendations;

● To determine if there is a need for the Colleges to develop new clinical

best practice guidelines for oral care of mechanically ventilated

patients/clients; and

● To make recommendations based on evidence and IPC practices to

registered respiratory therapists (RTs), registered dental hygienists

(RDHs), other health care providers, patients/clients and the public.

Electronic Survey

CRTO conducted a survey of RTs to:

● Explore current oral care practices of RTs and other health care

providers;

● Request the sharing of organizational policies and procedures; and

● Identify oral care champions (RTs) willing to participate in a focus

group.

Facilitated Focus Group

● 5 RTs and 3 RDHs were engaged from across Ontario and a variety

of practice settings

● Review current practices and evidence-based literature (clinical

and IPC)

● Make recommendations to the CRTO and the CDHO – to improve

patient/client care

● Generative Strategies Used – IPC icebreakers; brainstorming;

sequential questioning; small group work; process mapping;

roundtable discussions

Electronic Survey

Focus Group

Current Practice Review

● Invasive = Endotracheal Tube (ETT) or Tracheostomy Tube in situ

● Oral care practice varied from organization to organization

● Mostly based on Safer Healthcare Now! VAP recommendations for oral

decontamination

● Need to identify who was on oral care team

● Need to increase awareness and standardize oral care of invasively

ventilated patients/clients

● Recommendations could be extended to invasively ventilated

patients/clients in community

● Further recommendations for neonatal and pediatric populations; non-

invasively ventilated patients/clients should be considered in the future

Best Practice Recommendations for Oral Care of Invasively Ventilated Patients/Clients: An Interprofessional Collaborative (IPC) Project Between Two Health Regulatory Colleges in Ontario

Do you have an oral care protocol Policy/Procedure/Guideline

in place for patients/clients at risk of VAP?

Answer Options Response Percent Response Count

Yes 57.4% 58

No 20.8% 21

Don't know 21.8% 22

answered question 101

Oral Care Survey by CRTO:

118 responses

33% RTs involved in oral care of ventilated patients/clients

89% indicated mostly Nursing practice

8.5% indicated interprofessional approach

58% had oral care P&P (some willing to share)

No one had received any training from RDH

29% would like to participate in IPC focus group

Who is on the Oral Health Care Team?

Dental Hygienists Speech Language Pathologists

Respiratory Therapists Pharmacists

Nurses Dieticians

Physicians (e.g. Intensivists, Social Worker

ENT specialists, Oral Surgeons, Personal Support Workers

Anesthetists) Patient/client themselves

Dentists (e.g., in community, Family care givers

long-term ventilation)

Jennifer Harrison, RRT / Edited by Fran Richardson, RDH and Lisa Taylor, RDH

Background

Objectives of the IPC Project

Methods

Results

Conclusions

Other Challenges to Good Oral Care were identified:

Practicality of oral care prior to intubation in an emergent situation

Access to oral space (e.g., patient/client presenting condition,

trauma, infection, patient biting)

Patient/client awareness and understanding (e.g., Alzheimer’s,

dementia, mental health)

Patient/client compliance (e.g., physical ability, access to assistance)

At home: cost of oral care, support at home, access to competent

oral health care team

Fear of touching mouth (e.g., lack of understanding, victim of sexual

abuse)

As a team, ask:

What needs to be done? Evidence-based best practices,

guidelines, policy & procedure, competency, quality assurance

Who can? Consider legislative scope and perhaps controlled acts

involved (e.g., suctioning)

Who could? Use of authorizing mechanisms (orders, medical

directives, delegation) and human resources including the

patient/client, family and non-regulated health care professionals

Who should? What is in the best interest of the patients/clients

given the providers and practice setting

Who will? What is the plan where you work?

Formalize/standardize it.

1 Safer Healthcare Now! VAP Bundle retrieved from: http://www.saferhealthcarenow.ca/EN/Interventions/VAP/Documents/VAP%20Getting%20Started%20Kit.pdf 2 Stonecypher, K., (October-December, 2010). Critical Care Nursing Quarterly. Ventilator-Associated Pneumonia: The importance of oral care in intubated adults. Volume 33 No 4 pp. 339-347. 3 HealthForceOntario Interprofessional Care retrieved from: http://www.healthforceontario.ca/upload/en/whatishfo/ipcproject/hfo%20ipcsic%20final%20reportengfinal.pdf 4 International Federation of Dental Hygienists Conference, July 2011, Presentation: Plaque Biofilm Management: Restorative Microbiology and Tailored Comprehensive Oral Care. Research Review Speaker Series. 2011 Mar 17. 5 Canadian Interprofessional Health Collaborative (2010). A National Interprofessional Competency Framework – Quick Reference Guide. retrieved from: http://www.cihc.ca/files/CIHC_IPCompetenciesShort_Feb1210.pdf.

Acknowledgements

References

Invasively Ventilated

Patients/Clients

Adults

Hospital to

Home

Need oral

care

Health Care Team

Engagement

Commitment

Role Clarity

Enabled

Health Care Professionals

Aware

Educated

Competent

Enabled

Best Practices for Oral Care

IPC oral

healthcare

team

Evidence

based

Organized

Patient/Client Outcomes

Quality

Care –

Reduced

VAP

Safe Care

Ethical Care